Summary of Facility Monitoring
Facility Name: PEOPLE INC LEVEL D CHILDRENS HOME Date: 10/6/2026 Time: 11:56:57 PM
Case Number: K850000003



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Program Name PEOPLE INC LEVEL D CHILDRENS HOME Director Tammy Mills
Location 1606 E DOWNING
TAHLEQUAH, Oklahoma 74464 		E-Mail Address tmills@peopleinc.org
Program Phone (918) 506-8861 County of Facility Cherokee
Program Type Residential Program Subtype Residential
Residential Specialist Name Wayne Flanagan Residential Specialist
Phone Number 		(405) 397-9672
Capacity 9 Services Provided


Monitoring Summary since 10/6/2023
Listed below are the non-compliances OBSERVED during a visit. The regulation, its description, the non-compliance observed according to the regulation, and a plan of corrective action are all provided. The column "NRS" indicates Numerous, Repeated and/or Serious non-compliances with Licensing Requirements.
Visit Date 5/6/2026 Visit Type Full Purpose of Visit Periodic
RequirementRegulation DescriptionNonCompliance ObservedPlan To CorrectCorrection DateNRS
340:110-3-154(a)(6)Residents receive a medical examination by a licensed health care professional within 60-calendar days prior to admission or within 30-calendar days following admission. However, a documented medical exam performed within the 12 months prior to admission is acceptable when a resident is transferred from another licensed program.One resident file did not have verification of required medical examination. Documentation of medical examination will be obtained for resident and placed in file. 05/08/2026No
340:110-3-154(b)(2)(C)(v)names and dated signatures of review participants.Signature was not on review documents for one resident. Resident signature or statement of refusing/unable will be put on document. 05/08/2026No
340:110-3-154(d)(1)(H)signed documentation the resident and parents were provided copies of program policies.Resident signature was missing on document used to verify program policies were provided in two files reviewed during this audit. Resident signature or statement of refusing/unable will be put on document. 05/08/2026No
340:110-3-154(b)(1)Comprehensive service plan. A written service plan is developed and documented for residents within 30-calendar days of admission.Initial service plan was not on file for one resident. Initial service plan will be on file for resident. 05/08/2026No

Visit Date 1/15/2026 Visit Type Full Purpose of Visit Periodic
RequirementRegulation DescriptionNonCompliance ObservedPlan To CorrectCorrection DateNRS
340:110-3-154(a)(6)Residents receive a medical examination by a licensed health care professional within 60-calendar days prior to admission or within 30-calendar days following admission. However, a documented medical exam performed within the 12 months prior to admission is acceptable when a resident is transferred from another licensed program.Documentation of medical examination for one resident reflects date that exceeds 30 days from admission. Program will obtain documentation of medical examination meeting required time frame for all residents. 01/16/2026No

Visit Date 9/18/2025 Visit Type Full Purpose of Visit Periodic
RequirementRegulation DescriptionNonCompliance ObservedPlan To CorrectCorrection DateNRS
340:110-3-154(b)(1)(B)(vi)names and dated signatures of those participating in service plan development.No signatures obtained on initial service plan document for two residents. Dated signatures will be obtained on all initial service plan documents. 09/19/2025No
340:110-3-154(b)(2)(C)(v)names and dated signatures of review participants.No signatures obtained on service plan review documents for two residents. Dated signatures will be obtained on all service plan review documents. 09/19/2025No
340:110-3-157(k)(4)Broken, defective, or recalled furnishings and equipment are repaired or replaced.Two love seats in north cottage with leather peeling on arm rests and other cushioned areas of the furniture. Damaged furniture will be replaced. 10/01/2025No
340:110-3-153.1(l)Orientation. Personnel receive orientation after employment date and within 30-calendar days of employment.One personnel without verification on file. Program will submit documentation of completed orientation to licensing for personnel identified during this audit. 09/22/2025No

Visit Date 5/27/2025 Visit Type Full Purpose of Visit Periodic
RequirementRegulation DescriptionNonCompliance ObservedPlan To CorrectCorrection DateNRS
340:110-3-153.1(l)Orientation. Personnel receive orientation after employment date and within 30-calendar days of employment.Verification of completing orientation within required time frame not on file. Program will provide verification of completed orientation for personnel identified during this audit. 05/29/2025No

Visit Date 1/22/2025 Visit Type Full Purpose of Visit Periodic
RequirementRegulation DescriptionNonCompliance ObservedPlan To CorrectCorrection DateNRS
340:110-3-154(b)(2)(C)(v)names and dated signatures of review participants.Resident signature not obtained on review form and no reason is documented such as refusing or unable to sign is noted. Program will obtain resident signatures on service plan review documents or note a refusal or inability to sign. 01/22/2025No
340:110-3-157(k)(4)Broken, defective, or recalled furnishings and equipment are repaired or replaced.One couch in each cottage has torn areas that is exposing internal material. Program will repair or replace couches that are in disrepair. 02/28/2025No

Visit Date 9/17/2024 Visit Type Full Purpose of Visit Periodic
RequirementRegulation DescriptionNonCompliance ObservedPlan To CorrectCorrection DateNRS
340:110-3-154.5(c)(8)A first aid kit is available in the vehicle at all times.First aid kit not located in one program vehicle that was available to be observed. First aid kit will be placed in program vehicle that was identified during this audit. 09/17/2024No
340:110-3-163(15)(D)Programs maintain current dog and cat vaccinations administered by a licensed veterinarian.Two cats without current vaccination documentation on file. Program will obtain current pet vaccination record and submit to licensing. 09/20/2024No

Visit Date 5/9/2024 Visit Type Full Purpose of Visit Periodic
RequirementRegulation DescriptionNonCompliance ObservedPlan To CorrectCorrection DateNRS
340:110-3-154(b)(2)(A)The service plan is reviewed within 90-calendar days after development and at least every six months thereafter.Ninety day service plan review that was due by 3-13-24 was not on file for one resident. Program will place required documentation of service plan review in residents file for future review. 05/09/2024No
340:110-3-153.1(l)Orientation. Personnel receive orientation within 30-calendar days of employment.Two personnel without verification of completing orientation within required time frame on file. Program will place required documentation of orientation in personnel file for future review. Program will forward documentation to licensing personnel once obtained. 05/09/2024No

Visit Date 1/10/2024 Visit Type Full Purpose of Visit Periodic
RequirementRegulation DescriptionNonCompliance ObservedPlan To CorrectCorrection DateNRS
340:110-3-165(5)(B)Fire extinguishers. Fire extinguishers are provided in accordance with current adapted NFPA standard #10 "Portable Fire Extinguisher."Extinguishers in both cottages with expired tags as of 8-23. Program will contact service provider to inspect and currently tag all extinguisher in both cottages and notify licensing once completed. 01/10/2024No
340:110-3-163(1)(A)Exterior and interior surfaces are maintained in sound condition and free of holes, peeling paper, and paint.Peeling paint located in southwest and northeast bedrooms of south cottage. Program will submit a work order to have bedrooms painted and notify licensing once completed. 01/10/2024No
340:110-3-163(12)Electrical. The electrical distribution system is sized, installed, and maintained in a safe manner, per the Oklahoma Electrical Licensing Act. Portions of the electrical system constructed, repaired, or replaced after June 1, 1987, are installed, per the current National Electrical Code.South Cottage has an outlet cover missing in southeast bedroom and day room under extinguisher east of main entrance. Program will install outlet covers and notify licensing once completed. 01/10/2024No
340:110-3-157(h)Bathrooms. Bathrooms are maintained in a clean and sanitary condition with adequate ventilation.Bathroom located in west hallway of north cottage presented with mold on baseboard and unknown stains on wall and ceiling around shower and handwashing sink. Program will submit a work order to have repairs performed and will notify licensing once completed. 01/10/2024No




Complaint Summary since 10/6/2023
No data on file